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Chapter 17 Mood Disorders and Suicide Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Mood Disorders • Affective disorders – Pervasive alterations in emotions manifested by depression, mania, or both – Interference with life; long-term sadness, agitation, or elation • Individuals with mood disorders throughout history Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Mood Disorders (cont.) • Most common psychiatric diagnosis associated with suicide – Depression one of the most important risk factors for it Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Categories of Mood Disorders • Major depressive disorder • Bipolar disorder • Related disorders – Dysthymic disorder – Cyclothymic disorder – Substance-induced depressive or bipolar disorder – Seasonal affective disorder – Postpartum depression, psychosis, premenstrual dysphoric disorder – Nonsuicidal self-injury Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology • Biologic theories – Genetic theories – Neurochemical theories: serotonin, norepinephrine; possibly acetylcholine and dopamine – Neuroendocrine influences: hormones Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology (cont.) • Psychodynamic theories – Freud: self-deprecation – Bibring: ideal ego – Jacobson: superego over powerless ego • Mania: defense against underlying depression Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cultural Considerations • Masking of depression by other behaviors considered age appropriate – School phobia, hyperactivity, learning disorders, failing grades, antisocial behaviors – Substance abuse, gangs, risk behaviors, eating disorders, compulsive behaviors • Somatic complaints – Major manifestation among cultures that avoid verbalizing emotions Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Is the following statement true or false? • Depression is most commonly associated with suicide. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • True • Rationale: Depression is considered the most common diagnosis that results in suicide. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Major Depressive Disorder • Incidence: women to men 2:1 – Decreases with age in women; increases with age in men; highest in single, divorced people • 50% to 60% will suffer recurrence • Approximately 20% will develop a chronic form of depression • Symptoms range from mild to severe Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Major Depressive Disorder (cont.) • Symptoms: sad mood, lack of interest in life activities (2 weeks or more), and at least four other symptoms: – Changes in eating habits → weight gain or loss – Hypersomnia or insomnia – Impaired concentration, decision making, or problem solving – Worthlessness, hopelessness, despair, guilt – Thoughts of death/suicide – Overwhelming fatigue, negative thinking Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychopharmacology • Selective serotonin reuptake inhibitors (see Table 17.1) • Cyclic antidepressants (see Table 17.2) • Atypical antidepressants (see Table 17.3) • Monoamine oxidase inhibitors (MAOIs) (see Table 17.4) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Other Medical Treatments and Psychotherapy • Electroconvulsive therapy (ECT) • Psychotherapy (combined with medications) – Interpersonal therapy: relationship difficulties – Behavior therapy: reinforcement of positive interactions – Cognitive therapy: correction of cognitive distortions (see Table 17.5) • Investigational treatments Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Major Depressive Disorder and Nursing Process Application • Assessment – History – General appearance, motor behavior (psychomotor retardation, latency of response, psychomotor agitation) – Mood, affect (anhedonia) – Thought process, content (rumination, suicide) – Sensorium, intellectual processes (impaired memory) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Major Depressive Disorder and Nursing Process Application (cont.) • Assessment (cont.) – Judgment, insight (impairment) – Self-concept (worthlessness) – Roles, relationships (difficulty in this area) – Physiologic, self-care considerations – Depression rating scales • Self-rating scales: Zung, Beck • Clinician rating scale: Hamilton Rating Scale Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Is the following statement true or false? • Patients with depression often exhibit anhedonia. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • True • Rationale: Anhedonia refers to the loss of any sense of pleasure from activities that a person formerly enjoyed. This is a manifestation of depression. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Major Depressive Disorder and Nursing Process Application (cont.) • Data analysis/nursing diagnoses • Outcome identification – Free from self-injury – Improved mood and energy – Return to previous functional level – Medication compliance Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Major Depressive Disorder and Nursing Process Application (cont.) • Intervention – Providing for safety (suicide precautions) – Promoting therapeutic relationship – Promoting ADLs, physical care – Using therapeutic communication – Managing medications – Patient, family teaching • Evaluation Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bipolar Disorder • Extreme mood fluctuations from mania to depression (see Figure 17.1) • Second only to major depression as cause of worldwide disability • Onset usually in late teens, 20s, or 30s • Manic episodes begin suddenly, last from a few weeks to several months Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment • Psychopharmacology – Antimanic agent: lithium – Anticonvulsant agent used as mood stabilizer (see Table 17.6) – Agents helpful in reducing manic behavior, protecting against bipolar depressive cycles • Psychotherapy useful in mildly depressive or normal portion of bipolar cycle – Not useful during manic stages Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bipolar Disorder and Nursing Process Application • Assessment – History – General appearance, behavior (pressured speech, flamboyancy, sexually suggestive) – Mood, affect (euphoric, grandiose) – Thought process, content (circumstantiality, tangentiality) – Sensorium, intellectual processes (disoriented to time) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bipolar Disorder and Nursing Process Application (cont.) • Assessment (cont.) – Judgment, insight – Self-concept (exaggerated) – Roles, relationships (labile emotions) – Physiologic, self-care considerations • Data analysis/nursing diagnoses • Outcome identification – Free from injury—med compliance – Meet basic needs and self-care – Socially appropriate behavior Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Which of the following would be most appropriate for the treatment of mania associated with bipolar disorder? – A. Lithium – B. Fluoxetine – C. Citalopram – D. Venlafaxine Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • A. Lithium • Rationale: Lithium is an antimanic agent, which would be most appropriate for treating a manic patient with bipolar disorder. – Fluoxetine, citalopram, and venlafaxine are antidepressants. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bipolar Disorder and Nursing Process Application (cont.) • Intervention – Providing for safety – Meeting physiologic needs – Providing therapeutic communication – Promoting appropriate behaviors – Managing medications (see Tables 17.6 and 17.7) – Providing patient, family teaching • Evaluation Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Suicide • Intentional act of killing oneself • Suicidal ideation: thinking about killing oneself • Warning signs: risk for suicide (see Box 17.4) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Suicide (cont.) • Assessment: – Previous suicide attempts (first 2 years after— highest risk period, especially first 3 months); relative who committed suicide – Warnings of suicidal intent (see Box 17.4); risky behavior – Lethality assessment • Data analysis/nursing diagnoses Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Suicide (cont.) • Outcome identification – Safety, free from self-harm • Intervention – Authoritative role – Safe environment: suicide precautions; no suicide/no self-harm contract – Support system list Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Suicide (cont.) • Family response – Suicide as ultimate rejection of family, friends – Families react with guilt, shame, anger Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Suicide (cont.) • Nurse’s response – Need for unconditional positive regard for person – Avoidance of patient blame – Nonjudgmental approach, tone – Belief that one person can make a difference in another’s life – Possible devastation of staff if patient commits suicide Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Legal and Ethical Considerations • Assisted suicide as topic of national legal, ethical debate (Oregon, the first state to adopt assisted suicide into law) • Nurse often cares for terminally or chronically ill people with poor quality of life. • Nurse’s role to provide supportive care for patients, family as they work through decision-making process Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Is the following statement true or false? • When dealing with a patient who is suicidal, the nurse needs to assume a dependent role. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • False • Rationale: When dealing with a patient who is suicidal, the nurse must take an authoritative role. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Elder Considerations • Depression common among the elderly; marked increase when elders are medically ill – Psychotic features common – Increased intolerance to medications – ECT more commonly used for treatment; more rapid response • Suicide increased among elderly Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Community-Based Care • Nurses as first health-care professionals to recognize behaviors consistent with mood disorders • Successful treatment of depression in community by psychiatrists, psychiatric advanced practice nurses, primary care physicians Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Community-Based Care (cont.) • Bipolar disorder: referral to psychiatrist or psychiatric advanced practice nurse for treatment Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Health Promotion • Education to address stressors contributing to depressive illness • Efforts to improve primary care treatment of depression • Prevention and early detection, treatment for adolescents Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Health Promotion (cont.) • Screening for early detection of risk factors – Family strife – Parental alcoholism or mental illness – History of fighting – Access to weapons in the home Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues • Importance of dealing with own feelings about suicide • Frustration possible when working with depressed or manic patients • Exhaustion possible when working with manic patients • Journaling to help deal with feelings; talking with colleagues often helpful Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins